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47

BEST EVIDENCE EQUIPMENT REVIEW

The intubating laryngeal mask airway

A Steel
...............................................................................................................................

Emerg Med J 2005;22:47–49. doi: 10.1136/emj.2004.020644

T
he laryngeal mask airway (LMA) is accepted as both a reduced level of consciousness and is unable to maintain an
rescue ventilation and a primary airway management effective airway. Tracheal intubation by direct laryngoscopy is
device in both the prehospital and emergency depart- impossible. You wonder whether the prehospital use of an
ment environments.1–3 A modified version of the LMA, the ILMA as a primary airway management or rescue ventilation
intubating laryngeal mask airway (ILMA, LMA-Fastrach; device would be better than a standard LMA.
Intavent Ltd, Reading, UK) exists, which, when combined
with a modified tracheal tube, can be used for blind tracheal
THREE PART QUESTION
intubation. There is evidence that the ILMA is an effective
In [patients with a reduced level of consciousness] is [pre-
means of maintaining ventilation and oxygenation in the
prehospital,4 operating theatre,5 and emergency department6 7 hospital insertion of an ILMA] more or less likely to be
environments. In addition, it has been reported to be effective [successful and associated with effective ventilation and
in facial trauma,7 neck immobilisation,8 9 in a lateral oxygenation] compared with a standard LMA?
position,10 while wearing a chemical protective hood,11 and
while in a helicopter.12 Importantly, it has been shown to be SEARCH STRATEGY
effective even among inexperienced operators.6 8 13 14 A best Primary sources of evidence (Medline and Embase) were
evidence equipment review was undertaken to assess searched using [intubating laryngeal mask airway, intubat-
whether, when compared with a conventional LMA, the ing LMA OR Fastrach.mp] with Medline and [‘‘intubating
ILMA would be of use as an airway rescue device. laryngeal mask airway, intubating LMA OR Fastrach’’] with
Embase. This search strategy was checked with an informa-
DESCRIPTION OF DEVICE tion specialist. The same search strategy was applied to the
The ILMA is a modified version of the LMA, which, in Cochrane Library as a source of secondary evidence. In
addition to permitting ventilation, is designed to facilitate addition, a text word internet search and direct communica-
blind tracheal intubation with a tracheal tube in an obtunded tion with the manufacturer was undertaken.
or anaesthetised patient. It has a soft inflatable laryngeal
mask and a rigid, anatomically curved airway tube terminat-
ing in a standard 15 mm connector and is wide enough to
accept a cuffed 8 mm tracheal tube. The rigid handle permits
removal and ‘‘steering’’ of the device in relation to the larynx.
The device measures about 20 mm in transverse diameter at
its widest point. An epiglottic elevator bar in the mask
aperture elevates the epiglottis when an endotracheal tube is
passed through the aperture (fig 1)

PURPOSE AND INDICATIONS

The ILMA permits single handed insertion from any operator
position, without moving the head or neck from a neutral
position and without placing fingers in the patient’s mouth.
It can be used as an airway device in its own right, permitting
ventilatory control and oxygenation between intubation
attempts. Indications include use during difficult airway
situations, specifically including the need for manual in-line
stabilisation and situations where there is restricted access to
the patient or when personnel with intubation skills are not
available, or where there is suspected cervical spine injury.
The laryngeal mask component serves to guide the reinforced
tracheal tube directly to the glottis without displacing
anatomical structures. Unless the patient is deeply uncon-
scious or has had topical anaesthesia applied to their upper
airway, this will require concomitant neuromuscular block.
Intubation through the ILMA is contraindicated in the
presence of oesophageal or pharyngeal abnormality, although
oesophageal abnormality alone is not a contraindication to
the use of the ILMA purely as a rescue ventilation device.
Figure 1 The intubating LMA with modified tracheal tube component
CLINICAL SCENARIO inserted (with permission of The Laryngeal Mask Company Ltd). The
A young adult is involved in a road traffic collision resulting tracheal tube component shown is minus its detachable 15 mm
in a head injury and lower limb entrapment. He has a connector.

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48 Best evidence equipment review

Table 1 Relevant papers

Reference Study Outcomes Key results Weaknesses

15 Randomised crossover study
25 electively anaesthetised
patients with manual in-line
stabilisation. LMA crossed over
with ILMA. Randomised first
device selection
13 Randomised crossover study.
55 electively anaesthetised
patients. Randomised
to use either LMA or ILMA
16 Prospective study. 75 electively
anaesthetised patients. 24
inexperienced operators. LMA
crossed over with ILMA.
Randomised first device selection
(1) Speed of placement
(2) Ease of placement
(3) Adequacy of ventilation
based on chest movement,
compliance and the
presence of leak
(1) Speed of insertion
(2) Successful ventilation
as shown by positive
end tidal CO2
(1) Speed of insertion
(2) Adequacy of ventilation
based on chest expansion
and end tidal CO2.4kPa
(3) Pressure at which leak
developed around device
(1) Insertion of ILMA was
significantly faster than
LMA (p,0.001)
(2) Insertion of ILMA was
significantly easier than
LMA (p,0.001)
(3) Adequate ventilation
achieved in 100% of ILMA
insertions v 88% of LMA
(1) No significant difference
in mean insertion time
(2) No significant difference
in success of ventilation
(1) No significant difference
in insertion time
(2) No significant difference in
success of insertion or ventilation
(3) The ILMA was better at
providing adequate ventilation
without an audible leak p = 0.009
(1) Unblinded
(2) Hospital based ASA 1–2 patients
(3) Patients with neck/upper
respiratory abnormality or at risk of
aspiration excluded
(4) Muscle relaxants used
(5) Capnography/pulse oximetry not
used
(1) Unblinded
(2) Hospital based female patients
only
(3) Inexperienced operators
(4) BMI .30/reduced mouth
opening/reduced neck movements
excluded
(1) Unblinded
(2) Hospital based ASA 1–2 patients
(3) Inexperienced operators
(4) Patients with risk factors for
regurgitation excluded

SEARCH OUTCOME
There were no randomised controlled trials comparing the
use of the ILMA with that of a standard LMA in the
prehospital setting. Three hospital based research reports
were found to be relevant (see table 1).13 15 16
RESULTS
These studies suggest that, in hospital, the intubating
laryngeal mask is at least as quick and as easy to insert as
a standard LMA. The ILMA is more likely to provide
successful ventilation than a standard LMA. There were no
significant complications reported as a result of using an
ILMA.
PRACTICAL CONSIDERATIONS
Availability
Most UK anaesthetic departments will have the device
available as part of a difficult airway equipment set. Most
emergency departments and ambulance services, however,
will be unfamiliar with the ILMA and the prehospital care
practitioner can expect the need to assist emergency
department staff in its use.4 17
Presentation
The device comes packaged as three separate components—
the ILMA, a straight reinforced tracheal tube and a stabiliser
rod. The stabiliser rod is used to prevent dislodgement of the
tracheal component while the LMA component is being
extracted around it, although for short periods the LMA
component may be left in situ to facilitate airway control on
subsequent extubation. Three sizes are of ILMA are avail-
able—size 3 (children 30–50 kg), size 4 (adult 50–70 kg), and
size 5 (adult 70–100 kg). Use of a standard cuffed tracheal
tube (rather than the specifically designed tracheal tube) is
not recommended by the manufacturer.
Sterilisation
It is delivered non-sterile and must be cleaned and sterilised
before initial use and before each subsequent use. Steam
autoclaving is the recommended method of sterilisation. The
ILMA device can be reused up to 40 times. The dedicated
tracheal component can be steam sterilised and used up to 10
times. A single use plastic version of the ILMA is currently
awaiting CE approval and has an anticipated launch date of
early 2005. A single use dedicated tracheal tube will also be
available in late 2004.
Training
Complimentary video and manikin based training is provided
by the UK distributor (http://www.intaventorthofix.com).
This would normally be done within a half day session and
include theoretical training, maintenance, and two consecu-
tive successful manikin based insertions (which have been
shown to predict successful insertion and ventilation among
patients).18
Expiry
The device is reusable and warranted against manufacturing
defects for 40 uses or one year from the date of purchase
(whichever is earlier).
Cost
Single reusable ILMA: £304. Single reusable tracheal compo-
nent: £46. Complete set: £1050 (containing mask sizes 3, 4,
and 5 with reinforced tracheal tubes size 7, 7.5, and 8 and
three stabiliser rods). A reusable standard (non-intubating)
LMA is £91 and the disposable standard (non-intubating)
LMA (also available in sizes 3, 4, and 5) is £9 (Intavent-
Orthofix, personal communication).
CLINICAL BOTTOM LINE
There is reasonable evidence that the ILMA can be inserted
with as much success as a standard LMA with the additional
advantage of probable subsequent successful tracheal intu-
bation if necessary. Individual practitioners may find the cost
prohibitively expensive and the practical considerations of
sterilisation overburdening. However, single use versions are
expected to be significantly more affordable and should be
available soon. For prehospital care practitioners or systems
that regularly encounter difficult airways in patients anaes-
thetised or with reduced levels of consciousness, the ILMA is
a useful rescue ventilation and primary airway management
device that could be carried as an alternative to the standard
LMA.
Funding: this work was supported by the MAGPAS Research
Programme.
Conflicts of interest: none declared.

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Best evidence equipment review
Correspondence to: Dr A Steel, MAGPAS, 105 Needingworth Road, St
Ives, Cambridgeshire PE27 5WF, UK; a-steel@doctors.net.uk
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The intubating laryngeal mask airway

A Steel

Emerg Med J 2005 22: 47-49

doi: 10.1136/emj.2004.020644

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References This article cites 17 articles, 2 of which you can access for free at:
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